19783269-ncp-fever - assignment PDF

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ASSESSMENT Subjective ”Nurse, parang mainit ung nanay ko” as verbalized by the relative of the patient. Objective  Temperature: 38.6C  RR: 26cycle per minute   Hot, flushed skin  Increased respiratory rate  Diaphoresis  Warm to touch

NURSING DIAGNOSIS Hyperthermia related to bacterial infection. Definition: Body temperature elevated above normal range.

PLANNING Short Term After 1 hour of appropriate nursing intervention the patient’s temperature will decrease to 37.5oC. Long Term After 4 hours of appropriate nursing intervention the patient’s vital signs will return to normal range; with a temperature of 36.5-37.5oC,pulse rate of 60-100bpm and respiratory rate of 12-20 cycles per min.

NURSING INTERVENTION Independent 1. Monitor vital signs.

RATIONALE

 Vital signs provide more accurate indication of core temperature.

2. Provide tepid sponge bath. Do not use alcohol.

 TSB helps in lowering the body temperature and alcohol cools the skin too rapidly, causing shivering. Shivering increases metabolic rate and body temperature

3. Remove excess clothing and covers.

 These decrease warmth and increase evaporative cooling.

4. Promote a wellventilated area to patient.

 To promote clear flow of air in the patient’s area. One way of promoting heat loss.

5. Advise patient to increase oral fluid intake.

 Additional fluids help prevent elevated temperature associated with dehydration.

6. Maintain bed rest.

 Reduce metabolic demands/ oxygen consumption

7. Provide highcalorie diet.

 To meet increased metabolic demands.

8. Educate and advise support system (relative) to do TSB when patient feels hot. - Luke warm water only. - Make sure that armpits and groins were included in doing TSB.

 Teaching the Support system the right way to do TSB will help in knowing what to do in case the patient’s temperature increases

9. Monitored VS and recheck.

Dependent 10. Provide antipyretic medications as indicated.

 To know the effectiveness of nursing interventions done and to know the progress of patient’s condition.  These drugs inhibit the prostaglandin that serve as mediators of pain and fever....